Gender: Male ______ Female ______
Race: Caucasian ______ African American ______ Hispanic ______
Native American ______ Other ______
What are your credentials? LPN ______ RN ______
How many years experiences do you have working as a nurse?
0-5 years ______ 6-10 years ______ 11-15 years ______ 16 + years ______
Do you regularly provide education to diabetic patients in your current role?
Yes _____ No ____
Survey Questions:
1. Overall, are you satisfied with the diabetic education opportunities provided at RiverView Health?
f. Very satisfied g. Somewhat satisfied
h. Neither satisfied nor dissatisfied i. Somewhat dissatisfied
j. Strongly dissatisfied Please explain your response.
2. Do you feel you have enough time to provide comprehensive diabetic education to newly diagnosed type 2 diabetic (T2D) patients or T2D patients who fail to meet goal?
a. Strongly agree b. Somewhat agree
c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree Please explain your response.
3. Do you feel the diabetes-self management education (DSME) service will augment the education already available to T2D patients at RiverView Health?
a. Strongly agree b. Somewhat agree
c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree Please explain your response.
4. Do you anticipate the T2D patients to have positive outcomes from participating in a diabetes self-management (DSME) service?
a. Strongly agree b. Somewhat agree
c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree Please explain your response.
5. Do you anticipate the implementation of a diabetic self-management education service will improve T2D patient’s knowledge, confidence, and preparedness in the management of their diabetes?
a. Strongly agree b. Somewhat agree
c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree Please explain your response.
6. Do you feel the referral process will affect your daily clinic operations?
a. Strongly disagree b. Somewhat disagree c. Neither agree nor disagree d. Somewhat agree
e. Strongly agree f. NA
Please explain your response.
7. How likely are you to encourage your provider to refer T2D patients to the DSME service?
a. Very likely
8. What potential barriers do you anticipate in the implementation of the DSME service and/or referral process at RiverView Health? Please explain.
Patient barriers:
Staff barriers:
Financial barriers:
Time:
Other:
APPENDIX J. NURSING STAFF’S POST-IMPLEMENTATION SURVEY
Gender: Male ______ Female ______
Race: Caucasian ______ African American ______ Hispanic ______
Native American ______ Other ______
What are your credentials? LPN ______ RN ______
How many years experiences do you have working as a nurse?
0-5 years ______ 6-10 years ______ 11-15 years ______ 16 + years ______
Do you regularly provide education to diabetic patients in your current role?
Yes _____ No ____
Survey Questions:
1. Overall, are you satisfied with the diabetic education opportunities provided at RiverView Health?
a. Very satisfied b. Somewhat satisfied
c. Neither satisfied nor dissatisfied d. Somewhat dissatisfied
e. Strongly dissatisfied Please explain your response.
2. Do you feel the diabetes-self management education (DSME) service has augmented the education already available to type 2 diabetic (T2D) patients at RiverView Health?
a. Strongly agree b. Somewhat agree
c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree Please explain your response.
3. Do you anticipate the T2D patients to have positive outcomes from participating in a DSME service?
a. Strongly agree b. Somewhat agree
c. Neither agree nor disagree d. Somewhat disagree e. Strongly disagree Please explain your response.
4. How likely do you anticipate the continuation of the DSME service to improve T2D patient’s knowledge, confidence, and preparedness in the management of their diabetes?
a. Very likely b. Likely
c. Neither likely nor unlikely d. Unlikely
e. Very unlikely
Please explain your response.
5. Do you feel the referral process has affected the daily clinic operations?
a. Strongly disagree b. Somewhat disagree c. Neither agree nor disagree d. Somewhat agree
e. Strongly agree f. NA
Please explain your response.
6. How likely are you to encourage or continue to encourage your provider to refer T2D patients to the DSME service?
a. Very likely b. Somewhat likely c. Neutral
d. Somewhat unlikely e. Very unlikely
Please explain your response.
7. What barriers have you experienced during the implementation of the DSME service at RiverView Health?
Please explain.
Patient barriers:
Staff barriers:
Financial barriers:
Time:
Other:
8. Do you have any suggestions for improvement of the DSME service and/or referral process at RiverView Health? Please explain.
APPENDIX K. TYPE 2 DIABETES BASICS CURRICULUM OUTLINE
Session 1
- Your Feelings about Having Diabetes - Support Systems, What is Diabetes?
- Types of Diabetes
- Diagnosing Type 2 Diabetes the A1c Test - Type 2 Diabetes Risk Factors and Symptoms - Type 2 Diabetes Care Plan
- Checking your Glucose - Eating for Better Health, - Being Physically Active
- Are you Ready to Make Changes?
Session 2
- Your Emotional Health, Stress and Diabetes
- Reviewing Your Daily Log, High Glucose and Low Glucose - When You are Sick
- Mindful Eating for Better Health, Dining Out - Challenges to Being Physically Active - Weight Loss for Better Glucose Management - Goal Setting and Working Towards Your Goal Session 3
- Goal-Setting Checkpoint, Glucose Checkpoint, Problem Solving Using Your Records - Glucose Patterns
- Heart Health, Blood Pressure and Heart Health - Tobacco Use, Diabetes, and Heart Health - Eating for Better Heart Health
- Diabetes and Alcohol
- Physical Activity and Heart Health - Weight Loss and Heart Health Session 4
- Diabetes Changes over Time - Diabetes Complications
- Delaying or Preventing Diabetes Complications - Diabetes Care Schedule for Adults
- Taking Care of Your Feet - Getting Enough Good Sleep - Planning for Pregnancy
- Eating Mindfully, Not Emotionally - Keeping Physically Active
- When Life Gets in the Way - Setting More Goals - Your Support System
- Staying in Charge of Your Diabetes - Looking to Your Future
APPENDIX L. CLIENT SATISFACTION SURVEY
APPENDIX M. CLIENT SATISFACTION PERMISSION
APPENDIX N. SENIOR LEADER CONSENT FORM